the aging face and facial rejuvenation
DESCRIPTION
What is Facial Beauty? What makes someone more attractive is eye of the beholder and phi of the beholder. A look at how aging effects our beauty and what can be done to improve our facial beauty.TRANSCRIPT
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Facial Beauty Presented by
Dr. Scott K. Smith
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What is Beauty?
.
Is beauty only in the eye of the beholder….
Or ,are there some absolute values?
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Beauty is a mystery!
“I know not what beauty is but I know that it touches many things",
Dürer
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Symmetry youthfulness
clarity or smoothness of skin vivid color in the eyes and hair
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“Personal beauty is a greater recommendation than any letter of reference.”
- Aristotle
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Dental Emphasis to Oro-Facial
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• It has long been said that beauty is in the eye of the beholder and thought that beauty varies by race, culture or era.
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Beauty in the Eye of the Beholder?
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Beauty in the Phi of the Beholder
Evidence shows that our perception of physical beauty is hard wired into our being and based on how closely one's features reflect phi in their proportions.
• 1.6180399
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What is Phi
Phi ( Ø ), is simply an irrational number like pi. What makes it more unusual is that it can be derived
in many ways and shows up in relationships throughout the universe.Phi Ø can be derived through:
*A numerical series discovered by Leonardo Fibonacci
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Phi is Everywhere
* The proportions of the human body* The proportions of many other animals* Plants* DNA* The solar system* Art and architecture
The ratio, or proportion, determined by Phi (1.618...) was known to the Greeks as the "Golden Section" and to Renaissance artists as the "Divine Proportion
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Divine Proportion is Everywhere
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• The head forms a golden rectangle with the eyes at its midpoint. The mouth and nose are each placed at golden sections of the distance between the eyes and the bottom of the chin.
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• Science writer Eric Haseltine claimed (in an article in Discover magazine in September 2002) to have found that the distance from the chin to the eyebrows in Langlois's 32-composite faces divides the face in a Golden Ratio.
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• A similar claim was made in 1994 by orthodontist Mark Lowey, then at University College Hospital in London. Lowey made detailed measurements of fashion models' faces. He asserted that the reason we classify certain people as beautiful is because they come closer to Golden Ratio proportions in the face than the rest of the population.
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• Beauty is not just in the eye of the beholder. Researchers say it's also in the distance between the eyes and the mouth.
• Researchers at the University of California, San Diego and the University of Toronto have identified the optimal relation between the eyes, the mouth and the edge of the face that distinguishes a beauty queen from a plain Jane.
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Principles of Aesthetics
• Balance• Rhythm• Proportion• Emphasis• Unity
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Aesthetic Principles
• Balance• Rhythm• Proportion • Emphasis• Unity
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Balance
• Visual Equilibrium• Symmetry?
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Symmetry R and L superimposed
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Rhythm• The human face communicates an
incredible array of emotions which are an integral element of one's total beauty. The human face conforms most closely to phi proportions when we smile.
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Unity
• Coherence of the whole• Effect of all other disciplines working
together to form esthetic harmony
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Proportion
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Horizontal Fifths
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Emphasis
• Eyes• Cheeks• Peri-oral
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The Aging Face
• Extrinsic Factors
• Intrinsic Factors
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The Aging Face
Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S
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Extrinsic Factors
Trauma
Smoking
Photodamage
Gravity
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Intrinsic Damage
• Fibroblastic Synthesis Reduction
• Breakdown of Cellular Membrane
• DNA Repair Reduction
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Components of Aging
• Thinning of Dermis• Atrophy of Fat Pads• Loss of elasticity• Greater Visibility of Bony Landmarks• Increased Visibility of Vessels• Increased Mental and Mandibular Folds
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Components of Aging
• Development of Wrinkles and Furrows• Transverse Forehead lines• Drop of Eyebrow and Eyelid• Descent of Corner of Mouth• Thinning of Upper lip and Inversion of lip• Nasiolabial Fold Development• Rhytids – smokers lines• Atrophy of Cupids Bow
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Aesthetic Principles
• Balance• Rhythm• Proportion • Emphasis• Unity
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Principles we CAN effect
ProportionEmphasisRhythm
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Lips
what defines lip structure and attractiveness.
• Dentition • Width of upper vs. lower • Interlabial gap • Oral commissures should be located along vertical lines
drawn from the medial limbus of the iris.
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Gordon Classification
• Zone A• Zone B• Zone C
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Creating the Esthetic Smile
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SNC00140.3g2
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Aesthetic Treatments
Minimally Invasive Cosmetic Procedures
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• Botulinum toxin type A (BoNT-A) works by blocking the release of a neurotransmitter necessary for muscles to contract
• The effects of BoNT-A last approximately 3-4 months, with complete re-activation of the nerves and muscles
• BoNT-A has been available and used for therapeutic uses since 1980
Botulinum toxin
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Normal Neuromuscular Function
Arnon et al. JAMA 2001;285(8):1059-1070 (with permission).
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Botulinum Toxin Mechanism of Action
Arnon et al. JAMA 2001;285(8):1059-1070 (with permission).
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Botulinum Toxin Structure
1Hathaway. In: Hauschild AHW, ed. Clostridium Botulinum: Ecology and Control in Foods New York, NY: Marcel Dekker, Inc.;1993;54:pp 3-20.
2Inoue et al. Infect Immun 1996;64:1589-1594.3Lacy et al. Nat Struct Biol 1998;5:898-902 (with permission).
150 kD Neurotoxin
Non-toxic, non-hemagglutinin
(NTNH)
Hemagglutinin (HA)
Clostridium botulinum is a gram positive, anaerobic, rod-shaped bacterium that produces seven serologically distinct neurotoxins (A-G)1.
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Facial Areas Commonly Treated with BoNT-A
Forehead
Brow lift
Perioral lines
Platsymal bands
Glabellar lines
Oral commissures
Peau d’orange
Gummy smile
Crow’s feetBunny lines
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1. Frontalis
2. Procerus
3. Corrugator supercilli
4. Depressor supercilli
5. Temporalis
6. Obicularis oculi
7. Nasalis
8. Levator labaii superioris alaeque nasi
9. Levator labaii
10. Zygomaticus minor
11. Zygomaticus major
12. Obicularis oris
13. Modeolus
14. Masseter
15. Depressor anguli oris
16. Depressor labii
17. Mentalis
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15
16 17
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BoNT-A treatment: Glabellar lines
Before After - Day 30
www.Botox.com
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BoNT-A treatment: Forehead lines
Carruthers & Carruthers. Dermatol Surg 2007;33:S10-S17
Before After - Day 30
After - Day 120
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BoNT-A treatment: Brow lift
Before After
Coleman & Carruthers. Dermatol Therap 2006;19:177-88
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BoNT-A treatment: Perioral lines
Kane. Oral Maxillofacial Surg Clin N Am 2005;17:41-49
Before After
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BoNT-A treatment: Gummy smile
Kane. Oral Maxillofacial Surg Clin N Am 2005;17:41-49
Before After
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BoNT-A treatment: Oral commissures
Carruthers & Carruthers. Dermatol Surg 2003;29:468-76
Before After
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Hyaluronic Acid Fillers
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HA Treatment: Marionette lines
Before After
Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S
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HA Treatment: Pre-jowl sulcus
Smith. Plast Reconstr Surg 2007;120(Suppl):67S-73S
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HA Treatment: Lip Volumization
Before After After
Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S
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HA Treatment: Nasolabial folds
Before
After
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HA Treatment: Nasolabial folds
Before After – 2 weeks After – 38 weeks
Smith et al. AAD Summer 2006
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HA Treatment: Nasolabial folds
Before After – 2 weeks After – 24 weeks
Smith et al. AAD Summer 2006
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HA Treatment: Cheek Volumization
Before After – 10 days
Smith. Plast Reconstr Surg 2007;120(Suppl):67S-73S
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Introduction to
The Next Generation In Longer Lasting Wrinkle Correction
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Radiesse vs CosmoPlast® Clinical Study
Radiesse Control
Baseline 6 Months
Radiesse Control
Patient 1
Patient 2
Radiesse Control Radiesse Control
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Placement of Radiesse into the Skin
Subdermal PlaneSubdermal Plane
• Objective is to fill the depression and structurally support the line and provide volume– Inject Radiesse into the deep dermis and subdermal plane– Use non-dominant index finger to guide needle– Deeper threads can be placed to bolster depression– Use thumb and forefinger to massage and mold Radiesse
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Radiesse Delivers Greater Improvement Than Restylane At Every Time Point
Radiesse vs. RestylaneHow much improvement on average over time?
0
0.2
0.4
0.6
0.8
1
1.2
3 mo's 6 mo's 9 mo's
Time post 2nd injection
Me
an
Imp
rov
em
en
t fr
om
Ba
se
line
(W
SR
S)
Radiesse Improvement
Restylane ImprovementRADIESSE
RESTYLANE
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% Patients Improved at 9 months:
Radiesse = 79%
Restylane = 44%
• More Patients are Improved at Every Time Point
Radiesse Delivers Longer Lasting Improvement
Radiesse vs. RestylaneImprovement over Time (GAIS)
0
10
20
30
40
50
60
70
80
90
100
3 mo's 6 mo's 9 mo's
Time post 2nd injection
% o
f P
atie
nts
wit
h I
mp
rove
men
t
Radiesse
Restylane
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Radiesse & Restylane Histology – 4 weeks
Restylane• Minimal tissue response• No native fibrinogen, elastin and
collagen is manufactured to replace absorbtion of HA
RadiesseModerate tissue response
Gel carrier replaced by native fibrinogen, elastin and collagen under the normal
tissue repair mechanism
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Mechanism of Action
When placed into soft tissue, Radiesse provides immediate correctionGel + CaHA Particles
When placed into soft tissue, Radiesse provides immediate correctionGel + CaHA Particles
Over time the gel is resorbed and the CaHA particles stimulate and support in-growth of new collagenCollagen + CaHA Particles
Over time the gel is resorbed and the CaHA particles stimulate and support in-growth of new collagenCollagen + CaHA Particles
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Radiesse vs Restylane® Split Face Study
Restylane Radiesse
6 Months (post last injection)
9 Months (post last injection)
Restylane Radiesse
Before Treatment
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Addressing Some Misconceptions
1. Radiesse cannot form bone in soft tissue
• Micro-motion presence; No bone morphogenic proteins; No osteoblast progenitor cells
2. Radiesse particles do not migrate
• Exhaustive pre-clinical studies have demonstrated no migration
• Particles are 25-45µm & thus too large (>15 microns) to be encapsulated by macrophage and migrate via lymphatic system
• Collagen infiltration around particles hold them in place
3. Radiesse will not obstruct X-rays
• If visible, its only faint & whispy and won’t interfere
• Barely visible on diagnostic x-ray, clearly evident bilaterally on CT scan with no masking of other structures
4. Lip Nodules are not Granulomas
• Zero granulomas reported in multicenter clinical trials (>1,000 patients)
• CaHA molecular and chemical composition is identical to that in the human body and does not generate a foreign body Rx
• Not seen as a foreign body so no delayed inflammatory response
• Not for use in lips due to muscle motion & cohesive properties of the gel carrier
• Nodules are not granulomas – nodules are early onset, accumulations of product, which are distinct from late onset
granulomatous foreign body reactions
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Fractional CO2 Resurfacing
June 2011
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Resurfacing History
Ablative CO2 Full Resurfacing 1991
Erbium 1997
Non-Ablative Resurfacing 1996 IPL 1996
Nd:YAG & Others 2000
Non-Ablative Fractional Resurfacing 2004 Fraxel
Ablative Fractional Resurfacing 2006 CO2 & Erbium
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Rhytides
Scars
Rhytides
Scars
Tone
Texture
Color
Tone
Texture
Color
Low Energy
+ High Density
Low Energy
+ High Density
2. Photo courtesy of Mark Taylor, MD2. Photo courtesy of Mark Taylor, MD3. Photo courtesy of Yasmina Carvajal, M.D.3. Photo courtesy of Yasmina Carvajal, M.D.
Target of TreatmentPhoto
Damage
Photo
Damage
1. Photo courtesy of Mark Rubin, M.D.1. Photo courtesy of Mark Rubin, M.D.
2. 2.
1. 1.
3. 3.
Moderate Energy
+ Moderate Density
Moderate Energy
+ Moderate Density
High Energy
+ Low Density
High Energy
+ Low Density
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124
• When the laser pulses at thousandths of a second, the water in skin (skin is 90% water) heats up to a very high temperature.
• The water is instantly vaporized into a smoke plume and residual heat, proportional to the pulse energy (mJ), spreads into the surrounding tissue.
• Immediate contraction and epidermal dyschromias are removed.
• Ablated tissue and thermal spread of heat causes a natural healing response that stimulates new collagen growth to restructure and restore the dermis to resemble new, undamaged skin.
Ablative Lasers
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Immediately After Post 2 Days
• Ablated epidermis• Ablated column extends deep into
the dermis. • Uniform thermal heat to sur-
rounding tissues.
• Volume collapse of ablated column for
immediate contraction. • Re-epithelialization is complete. • Ongoing collagen stimulation for 3-6
months
Wound Healing
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Wound Healing Time
Stratum Corneum: 2 – 3 Days
Basal Layer: 4 – 6 Days
Papillary Dermis: 7 – 8 Days
Mid Dermis: 8 – 10 Days
Reticular Dermis: 10 – 12 Days
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Full Ablative CO2 Resurfacing
The “Gold Standard”
Single Treatment
Dramatic ResultsPhotos Courtesy of Dr. Sarnoff
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Full Ablative CO2 Resurfacing
• It was the “Worst of times”• Prolonged downtime (up to 1month)• Increased incidence of side effects• This is why we provide Erbium!
Photos Courtesy of Dr. Sarnoff
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Fractional CO2 Fractional CO2 Traditional CO2Traditional CO2
2 mm2 mm 150 µm150 µm
Full Face Ablation
Prolonged HealingFull Face Ablation
Prolonged Healing
Tissue Sparing
Shortened HealingTissue Sparing
Shortened Healing
Decrease need for power
Increase need for scanning
Decrease need for power
Increase need for scanning
Old vs. New Technology
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A fraction of the skin area is treated with an array of relatively small spots.
frac·tion·al- of, relating to, or being a
fraction- relatively small: inconsiderable
frac·tion·ate- to divide or break up- divide into different portions
Fractional Laser Treatment
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Any Golfers out there?Very Similar theory….
To improve the condition of the green, Golf Course Superintendents don’t remove the entire putting green, they remove a portion, or fraction of it!!!
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What’s Happening Today……
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Pigmentation Problems?
Courtesy of Nora Grace
Hair Problems ?
Wrinkles?
Acne?
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Hair Removal, Skin Rejuvenation,
Acne Treatments, Vascular Treatments
and Skin Tightening______________________________________________________________________________________________________________________________________________________________
__ The Multi-Application Intense Pulsed Light System
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What is Intense Pulsed Light?
• Broad Spectrum Light Source– 420 to 1200 nm wavelength range– Filtered wavelengths to provide multiple applications
• Delivered in Millisecond Pulses– Pulse duration 2ms to 9ms– TPW (total pulse width) from 10ms to 500ms– Up to 16sec in Skin Tightening
• High Energy Output– 50j/cm2 max energy– 22 – 35j/cm2 typical treatment parameters
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• Multiple Applications– Hair Removal, Photo Rejuvenation, Pigmented Lesions, Vascular
Lesions, Acne, Small Veins, Rosacea, Fine Lines
• Popularity of skin rejuvenation treatments– Excellent for clearance of sun damage, pigmented lesions, vascular
lesions, fine lines, and acne
• Fast and effective hair removal– 40 x 10mm square spot Vs 6, 8, 10, 12mm round spot– Excellent long term results – rivals laser technology
Why Use Intense Pulsed Light?
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Wavelength Penetration
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What is Variable Pulsing?
• New method of delivering Pulsed Light energy in a safe and effective manner
• Allows for peak power adjustments– Peak power is the measure of total energy/ time– NaturaLight adjusts for high peak power when needed (fine hair,
light pigment, ect) , low peak power (coarse hair, larger vascular) or medium power, depending on treatment parameters, goals, etc.
• Peak power adjustments increase efficacy• Peak power adjustments increase safety• These manipulations dramatically alter the way the
energy is delivered to the skin and allow increased controls for the physician
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FotoFacial, PhotoRejuvenation, Skin Rejuvenation, IPL Skin Treatments…
What do these treatments do?
Improve the tone and texture of the face, neck, chest, hands, etc.
Tone• Pigmentation, vascular, flushing, broken capillaries• All caused by sun damage
Texture• Treatments reduce fine lines, reduce the appearance of
pores, add laxity to the skin
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Non-Ablative Photo Rejuvenation
What patients want…
• No downtime• Affordable procedure• Fresh and healthy looking skin• Painless and easily tolerated
treatment• Safe and effective
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Photo Rejuvenation
• Patient consult– Expectations– Herpes prophylaxis?
• Treatment coarse and follow up– After care
• Technique and settings• Complementary treatments
– Microdermabrasion.– Cosmeceuticals– Botox– Sunless Tanning
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Pigmentation Problems
Courtesy of Focus Medical
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Pigmentation Problems
Courtesy of Saratoga Aesthetics
Immediate Post Treatment
30 days later
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Pigmentation/Melasma
Outstanding results from typically very stubborn pigmentation
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Skin Tightening – Before/After
The jaw line and neck was the focus of the treatment.
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Vascular Lesions Rosacea - Treatments reduce the
overall redness and flushing Facial Veins – Small broken capillaries up to 1mm diameter Other Vascular Lesions –
hemangioma, cherry angioma, PWT
Vascular Treatments
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Small Facial Veins
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Vascular Before and After
Look at the flushing and redness of the neck with this patient. The after picture shows a much more even tone without the visible redness.
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Facial Areas Commonly Treated with BoNT-A
Forehead
Brow lift
Perioral lines
Platsymal bands
Glabellar lines
Oral commissures
Peau d’orange
Gummy smile
Crow’s feetBunny lines
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Nasofacial Angle
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Frankfort Plane
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Mentocervical Angle
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